Accidental Poisoning in Childhood

Arch Dis Child: first published as 10.1136/adc.28.140.259 on 1 August 1953. Downloaded from

ACCIDENTAL POISONING IN CHILDHOOD

BY J. 0. CRAIG and M. S. FRASER From the Royal Hospital for Sick Children, Edinburgh, and the Department of Child Health, University of Aberdeen (RECEIVED FOR PUBLICATION MARCH 25, 1953) A recent increase in the number of children on a second occasion. the incidents have been brought to hospital with accidental poisoning has recorded as separate cases. This happened only been noticed in Edinburgh and Aberdeen. In a twice; there were 502 poisonings which concerned study of this trend, which has also been recorded 500 children. in Manchester (Holzel and James, 1951), we have The figures on which our diagrams are based are tried to determine whether it reflects a true increase grouped in Appendix A, and the statistical analyses of poisoning in the child population. We have then of the graphs will be found in Appendix B. compared the incidence of the individual toxic agents and the mortality from each in order to show which Icidence poisons are most in need of control. In 1931 about five cases were brought to the hospitals each year; by 1951 the number had risen Material to more than 50 (Fig. 1). This tenfold increase is Protected by copyright. Five hundred and two case-records have been 70 examined of children under the age of 12 years who were accidentally poisoned in the years 1931 to 1951 60 inclusive. Two hundred and sixty-five were seen at the Royal Hospital for Sick Children, Edinburgh, u 50 and 237 at the Royal Aberdeen Hospital for Sick Children. The cases from these two hospitals were U. 40 found to be so both in and in similar, frequency the LU0 types of poison swallowed, that it has been possible 30 to combine them as a single source of material. In co addition, the Registrars-General have provided us 20 with the certified causes of death of 454 fatally z http://adc.bmj.com/ poisoned children. Poisoning by gas or smoke and bacterial food 10 poisoning have been excluded, and also poisoning which occurred while a known therapeutic risk was 1935 1940 1945 1950 being taken. We have discarded as harmless such FIG. 1.-All poisoning cases. Edinburgh and Aberdeen. Average incidents as the swallowing of insulin or soap, but time-trend shown as dotted line. have included all those in which poisonous substances were reputedly taken, whether symptoms striking, but does not in itself indicate that there on September 29, 2021 by guest. occurred or not. In-patients and out-patients have has been a rise in poisoning in the child population. been considered together, as a distinction between Social changes may have been largely responsible, them depends partly on circumstances, such as the causing parents to bring their children to hospital time of day at which a child reported. One hundred more readily. The effects of such changes can be and thirty-one of the Edinburgh children were assessed indirectly, in two ways: (1) By taking into admitted and 110 in Aberdeen. account the general increase in the work of the On all but one occasion (an accidental overdosage hospitals; (2) by comparing the incidence of poison- by injection), the poisons were ingested. Most of ing with that of a similar domestic accident, burns the cases were mild, and only two children died, and scalds. one of morphine and one of methyl salicylate Further evidence on the reality of the increase can poisoning. When a child returned after taking poison be obtained: (l) By studying the national mortality 259 260 ARCHIVES OF DISEASE IN CHILDHOOD Arch Dis Child: first published as 10.1136/adc.28.140.259 on 1 August 1953. Downloaded from from poisoning; (2) by classifying the hospital cases the rise of burns and scalds has been linear, but that according to the source of the poison. of poisoning curvilinear. Hospital Turnover. Is the increase in the number Mortality. Any true increase of poisoning should of poisoned children attending hospital simply a be reflected in the numbers of deaths from this cause. reflection of a general increase in the use of hospital Close correspondence cannot be looked for, since facilities? Fig. 2 shows that, even in relation to the the death rate can readily be affected by such factors 0-70 hospital turn- as improved treatment and changes in the common - ABERDEEN . over, there has types of poison. Swinscow (1953) has suggested that 0-60 -----EDINBURGH been a fivefold alteration in methods of certification may have been rise in poison- important after 1940, but the influence of this 0-50 ing.By its mag- appears doubtful. LU nitude this rise The annual numbers of deaths in Scotland are too a 0-40 suggests a true small for reliable analysis, but the outlines of the z increase of British and Scottish mortality figures (Fig. 4) are so ULU 0 30 poisoning in 40 Vs J ~ ~the population. I LU 0. o020 F - If there were a LU 30 growing ten- o Z 0 Z 010I - dency to bring BRITAIN LL. < trivial cases to 0 20 100 1_ W cI0~c 940 ..9..5 1950hospital, those I U .. c SCOTLAND co U) 1935 IY 1945 1950 seen in recent 10 51: YEAR yaswudb D years would be z _Z FIG. 2.-Al poisoning cases, Edinburgha Protected by copyright. Aberdeen, shown as percentage of turnover expected to be 1935 1940 1945 1950 of appropriate deparnents. lES severe than YEAR the earlier ones. Classification according to the FIG. 4.-Deaths from poisoning in childhood, Bntain and Scotland, severity of poisoning proved to be impracticable, shown as three-year moving averages. but a bald comparison of those who developed symptoms and those who did not, produced no similar in their general characteristics that it seems evidence that the poisonings now seen are less severe justifiable to compare our morbidity figures with the than they used to be. British mortality. Swinscow, taking account of Burns and Scalds. Burns and scalds resemble population changes, found no firm evidence of a poisoning in that they are domestic accidents, are continuing rise in poisoning deaths after 1940. often very mild, and affect a similar age group. When a longer period is considered, however, the Only the Aberdeen hospital figures have been used, impression of an increase dating from 1935 becomes as there has been a campaign in Edinburgh against clear, and this is strengthened by the previous long burning accidents. In Fig. 3 it will be seen that burns period of decline (Fig. 5). There is no evidence that http://adc.bmj.com/ n 300 50 U 200 ~40

c 100 30- U-

0 on September 29, 2021 by guest. Z 1935 1940 1945 1950 20, FIG. 3.-Burns and scalds, Aberdeen. Average time-trend shown as 0U dotted line. v 10 and scalds have increased by 150O% (from 100 to z 265 cases per annum) during the 21-year period. 1915 1920 1925 1930 1935 1940 1945 The relative rise in poisoning has been far greater, YEAR numerical of the but the difference in the strength FiG. 5.-Dcaths from poisoning, Britain. 1912-1949, shown as two groups is so obvious that comparison on a three-year movimg aseragesm percentage basis is scarcely justified. Of undoubted importance, however, is the fact that these household toxic agents of recent introduction have caused the accidents have not increased in the same manner; higher mortality, and the figures since 1935 are thus ACCIDENTAL POISONING IN CHILDHOOD 261 Arch Dis Child: first published as 10.1136/adc.28.140.259 on 1 August 1953. Downloaded from compatible with an increase of poisoning among From these lines of enquiry, it appears certain British children. that a sharp rise in accidental poisoning has occurred Sources of Poison. The 502 cases have been since 1948 in the child population. A lesser increase classified as follows: in the period 1935-1948 is suggested, but the evidence Gaoup 1. Household substances, e.g., disinfectants, for this is not conclusive. fuels, cleaning agents, insecticides .. . (203) Gtoup 2. Medicines. 2A. Those intended for internal use .. (185) 2a. Those intended for exteral application, e.g., liniments, nose and eve drops . (75) LL 40 GRouP 3. Vegetable matter, e.g., berries, seeds (35) GRoup 4. Source unidentified . . (4) Cases due to a single toxic agent may contribute to U 30 more than one group, e.g., those due to atropine are w 40 divided be- 2020

Groups UJn ~ ~MEDICINAL /tween ,3 2A,When2B and 3.the 10 -----HOUSEHOLD z

20 general trends 0 of the two large 1935 I940 1945 YEAR FIG. 8.-'Medicinal' poisoning cases, Edinburgh and Aberdeen a 10I groups are examined it Average time-trends shown as dotted lines. v______appears that Age and Sex. The age incidence of the whole series 1935 1945 medicinal is shown in Table 1. The mean age for both Edin- YEAR poisoning has burgh and Aberdeen cases lay between 32 and 33

FK;. 6.-Poisoning cases in the two main recently in- Protected by copyright. groups, EdiAburgh and Aberdeen, shown as creased much months. three-year 1 movmg averag more rapidly TABLE AGE INCIDENCE. than the household group (Fig. 6). This is of such importance that the two groups will be considered Age in Number of Age in Number of Years Cases Years Cases separately. Theincrease in poisoning due to household Under I.. 25 6-7 13 substances (Fig. 7) has been steady and linear, like that 1-2 .. 184 7-8 7 2-3 147 8-9 9 ,, 30 ABERDEEN 3-4 55 9-10 5 4-5 30 10-11 3 ------EDINBURGH 5-6 .. 15 11-12 1 u 20 Age was not quoted in 8 cases. Total, 502. U- 0 In Fig. 9 (Edinburgh cases only) attention is UJ directed to the early years of life. Although there is co http://adc.bmj.com/ 1935 1940 1945 1950 0-5 Z DATE FiG. 7.-'Household' poisoning cases, Edinburgh and Aberdeen. 6-11 I0 Average time-trend shown as dotted line. 12-17 32 of and it seems burns scalds; that it is to this group of 66 poisons that burns and scalds are most comparable. 13-2.3

38 Yet the percentage increase in the household group 24-29 on September 29, 2021 by guest. has been about four times as great as that of bums and 30-35 33 scalds, for what this type of comparison is worth. z In contrast to the household poisons, the medicinal 0 group altered sharply in incidence about the year Z 36-47 24 1948 (Fig. 8). It is true that changes in population or social custom might have increased the hospital incidence of poisoning, for example, by diverting patients from the family doctor to the casualty 4tg-59 1s department, but such a rise would not have affected the medicinal group alone. Some new influence is NUMBER OF CASES

indicated. FIG. 9.-Age-incidence of poisoning in the early years, Edinburgh. 262 ARCHIVES OF DISEASE IN CHILDHOOD Arch Dis Child: first published as 10.1136/adc.28.140.259 on 1 August 1953. Downloaded from TABLE 2 ANALYSIS BY HOUSEHOLD POISONS

Number of Cases in Edinburgh and Aberdeen Number of Deaths in Britain Disinfectants 39 Disinfectants 28 Kerosene 31 Caustic alkali 23 Turpentine. 25 Phosphorus 17 Bkach 22 Ammonia 11 Ammonia 16 Kerosene. 8 Dyes and inks 16 Acetic acid 6 Rat poison (phosphorus 4) 5 Arsenic, non-medicinal 5 Carbon tetrachloride 5 Nicotine 4 Potassium permanganate 5 Petrol 4 Caustic soda and potash ('Lye') 4 Cyanides 4 Petrol 3 Potassium bichromate 3 'Insecticide' 3 Soldering fluid (zinc and HCI) 3 Acetic acid 3 Hydrochloric acid 3 'Acid' Metaldehyde 3 Shoe polish, paint, D.D.T., 'oil', of each 2 Potassium permanganate 3 Turpentine, 'corrosive', sodium nitrate, carbon tetrachlonde, copper sulphate, 'insecticide'. sulphuric acid, of each Varnish, corrosive sublimate, red squill, oxalic acid, lead, Blue vitriol, 'cleaning fluid', oxalic acid, lead, sodium arsenate, potassium bromate, soldering fluid, furniture polish, 'garden potassium sulphide, zinc, zinc phosphide, benzine, 'paint fluid', naphthalene. formalin, 'brasso', of each I solvent', window polish, antimonv, methvl akohol, 'paint- brush wash', mercuric nitrate, potassium chromate, of each

TABLE 3 MEDICINES INTENDED FOR ORAL USE EXCLUDING ATROPINE

Number of Cases in Edinburgh and Aberdeen Number of Deaths in Britain Barbiturates 36 Strychnine 41 Protected by copyright. Iron (ferrous sulphate 21) 24 Iron 31 Salicylates 20 Quinine 20 Purgatives 15 Opium series 19 Opium seres 10 Salicylates 19 Antihistamines 10 Barbiturates 10 Ephedrine 4 Digitalis 9 Thyroid 4 Antihistamines 6 Stilboestrol 4 Purgatives 6 Sulphonamides 3 Amidone, chloral, of each 2 Amidone ('physeptone') 3 Amphetamine, ergot, isoprenaline, quinine, strychnine (in purgative tablets), of each 2 Digitalis, mist. arsenic and ipecac., bromide, mandelate tabs., Ipecacuanha, sulphone, 'irritant pills', 'kerol'. of each 1 Lugol's iodine, nitroglycerine, chloral, pethidine, of each I

TABLE 4

MEDICINES INTENDED FOR EXTERNAL USE EXCLUDING ATROPINE http://adc.bmj.com/

Number of Cases in Edinburgh and Aberdeen Number of Deaths in Britain

Camphor . 29 Methyl salicylate (oil of wintergreen) . 36 Iodine 11 Camphor .. 12 'Liniment' 6 Lethane ..5 Sassafras .5 'Liniment' . . . . 2 Eucalyptus .. 4 Methyl salicylate (oil of wintergreen) 3 'Three oils', surgical spirit, of each . 2 Gentian vioket, bonc acid, 'eardrops', benzyl benzoate, cala- Ol. citronella, iodine, eucalyptus, 'tar preparation' of each . . I mine lotion, 'contraceptives', of each I on September 29, 2021 by guest.

TABLE 5 VrEGETABLE MATTER EXCLUDING ATROPINE

Number of Cases in Edinburgh and Aberdeen Number of Deaths in Britain Laburnum. 15 Fungi ...5 'Bernes' I10 Water dropwort ...4 Gween elderberries ...... 2 'Berries' . .. 2 Hemlock. .. 2 Daphne berries, mistletoe, whinseeds, fungus, sycamore seeds, Privet 1 poppy heads, of each.I Arch Dis Child: first published as 10.1136/adc.28.140.259 on 1 August 1953. Downloaded from ACCIDENTAL POISONING IN CHILDHOOD 263 TABLE 6 ATROPINE GROUP Number of Cases in Edinburgh and Aberdeen Number of Deaths in Britain Atropine evedrops . 5 'Belladonna' . 8 Belladonna mrxtures 2.. Dead1v nightshade 7 Deadly nightshade (clinical) 1 'Nightshade' 2 'Atropine' 3 Belladonna tablets I. Hvoscine (medicinal).. 6 'H%oscvamus' ..3. Henbane !Hvoscvamus niger) .. . Foods nightshade (bitterssweet) .. .. 1 Woody nightshade ...... 3 a peak in the second year, poisoning is frequent Poisoning is not always recognized, and figures throughout the pre-school years. There was no for the occurrence of lead, nicotine (usually insecti- significant change in age incidence after 1948. The cide), and cyanides, for instance, must be accepted vegetable group of poisons affects older children; with reserve. of 15 who had eaten laburnum seeds, for instance, Table 3 brings out clearly the importance of the mean age was 5 years 9 months. ferrous sulphate. The barbiturates and aspirin are About three boys were poisoned for every two prominent, and the toxicity of strychnine is particu- girls. This in itself is not significant, but it agrees larly striking in view of its apparently low incidence. with the figures of Ryan (1951) for sex incidence in Digitalis and quinine are also rare but dangerous. Queensland and Swinscow's figures for mortality. A few deaths are attributed to purgatives, but some of these may have been due to other ingredients of Frequency of Individual Poisons compound tablets, such as atropine or even strych- In order to discover which poisons are most nine.

common in childhood and which are most lethal, Camphor liniments are prominent in Table 4. Protected by copyright. Tables 2-6 have been drawn up to compare incidence Methyl salicylate (oil of wintergreen) resembles and mortality. The incidence is derived from our strychnine in that it is a rare poison with a very high 502 cases. The mortality is based on the deaths from mortality. Iodine is very seldom fatal, but lethane accidental poisoning (excluding gas and food is dangerous. poisoning) of 454 British children under 10 years of In Tables 5 and 6 a direct comparison between age. Five hundred and one deaths occurred in the incidence and mortality is not justified, owing to 21-year period (Fig. 4), but the certified causes are differences in flora between Scotland and England. obtainable only for 401 in England and Wales in the Deadly nightshade is the most dangerous of the years 1931-49 and for 53 deaths in Scotland in vegetable poisons, although uncommon in Scotland. 1939-51. A few cases had to be excluded from the Laburnum poisoning is common; death from this tables because the poisons were not named with cause has been recorded, but is very rare. sufficient accuracy. The chief results of the preceding tables are These tables must be studied with an important summarized in Table 7, in which the virulence of a http://adc.bmj.com/ reservation, that the comparison is between incidence TABLE 7 in Scotland and mortality derived largely from THE MAIN POISONS ASSESSED AS REGARDS POTENTIAL England. Reasons have already been given for the DANGER quantitative use of the British mortality figures. Frequency Number That a qualitative use is also justified will appear in Agent (Edinburgh Mortality of and (Britain) Deaths Table 7. This table shows the pattern of fatal Aberdeen) (Scotland) poisoning in Scotland, and also shows that the Disinfectants --. - 8 Scottish and English patterns are remarkably Barbiturates 0 on September 29, 2021 by guest. Kerosene ...... ---- O similar. Crude as it is, this method of comparison Camphor .. . --- -- 0 useful information. Turpentine .. ..-- - 0 provides Iron. .. ------7 Table 2 shows that the most important household Bleach . .. --- _ 0 Salicylates . 4 poisons are disinfectants, kerosene, caustic alkalies, Ammonia.. ._ __ 2 The of Atropine series . -- __ 0 and phosphorus (rat poison). group acids, Antihistamine .. . - excluding carbolic, accounted for 16 deaths. Turpen- Opium series -- __ 2 Phosphorus 0 . 0 tine and bleach are common poisons but are very Strychnine .. - ____ 8 seldom fatal; no death has been attributed to bleach Methyl salicylate . 6 Quinine . 3 in the last 20 years. Non-medicinal arsenic,potassium Caustics ('lye') . - ___ 0 permanganate and carbon tetrachloride are un- * An incidence or mortality of 1-9 cases has been scored as common poisons but carry a fair mortality. 10-19= 20-2911 and over 30= 19 Arch Dis Child: first published as 10.1136/adc.28.140.259 on 1 August 1953. Downloaded from 264 ARCHIVES OF DISEASE IN CHILDHOOD particular poison can be roughly measured by the hand, the deaths from ferrous sulphate show a relation between the frequency of its occurrence and steady increase. It had been responsible for a con- the frequency of death. siderable number of deaths before the danger of The Changing Incidence of Certain Poisons. In iron poisoning was generally recognized. The deaths Table 8 the numbers of cases attending hospital due of 17 British children were certified as due to ferrous years Forbes TABLE 8 sulphate poisoning in the 10 before THE INCIDENCE OF CERTAIN POISONS OVER A 21-YEAR (1947) described it, and one child had died of ferric PERIOD carbonate poisoning. 1931- 1934- 1937- 1940- 1943- 1946- 1949- The Principal Childhood Poisons. The only poison Agent 33 36 39 42 45 48 51 which is both common and very dangerous in

Disinfectants 4 4 5 6 8 2 10 Britain at present is ferrous sulphate. Indeed, had Kerosene 0 1 4 3 11 2 10 Turpentine 2 1 6 0 4 6 6 the mortality details been available for England and Ammonia . 0 1 2 1 3 5 3 Wales in 1950-51, the figure for ferrous sulphate Bleach 0 0 0 4 21 7 Camphor 3 0 3 8 6 3 might well have been higher. The same applies to Other applica- amidone and the antihistamines, drugs of recent tions .. 3 2 5 8 13 Purgatives 0 01 4 2 4 origin which are dangerous to children.* Aspirin .. 0 2 3 Barbiturates . . 0 0 0 4 3 9 Two rare poisons, strychnine and methyl salicy- Ferrous sulphate 0 0 0 0 4 late, are so virulent that they have caused the greatest Vegetable group 3 2 8 numbers of deaths during the 21-year period and have taken a steady toll throughout. Strychnine is to the commoner poisons are shown in three-year most in the form of tonic or laxative groups. The household poisons (Nos. 1-5) have risen taken often tablets. Other poisons which are rare but dangerous slightly, as have the medicinal applications (Nos. are and phosphorus Protected by copyright. 6-7). In the group of internal nmeicines (Nos. 8-1 1), quinine, digitalis, morphine only the purgatives follow the trend of the household (rat poison). are very common but carry only group; the others show a much steeper recent The barbiturates increase. The sharp rise in ferrous sulphate poison- a moderate risk to life. It is probable that the in childhood has been ing is not surprising, but it should be realized that toxicity of phenobarbitone exaggerated, since its danger in the individual case the barbiturates and aspirin are increasing in a of household manner only slightly less striking. The figures for appears to be less than that aspirin, or oil (Table 7). Kerosene the vegetable group have risen unexpectedly in the ammonia, camphorated common, but seems to cause few deaths. post-war years. If there should prove to be a true is also in this will remain to be However, some deaths due to kerosene may have increase vegetable poisoning, been the complications. explained. We can offer no convincing reason for it. registered under lung Disinfectants are still commonly swallowed, but In looking for any trend in mortality, we have had have diminished with the to use the figures for England and Wales only in deaths due to this group

for and http://adc.bmj.com/ six-year groups (Table 9). The danger of attaching substitution of less toxic substances phenol cresol. Caustic alkalies (lye), although apparently rare TABLE 9 in Scotland, are common and dangerous elsewhere. NUMBERS OF DEATHS FROM CERTAIN POISONS, ENGLAND AND WALES It is true that local custom and conditions modify the pattern of accidental poisoning. In California, Agent 1932-37 1938-43 1944-49 for instance, the commonest toxic agent in childhood Aspirin . . 2 5 9 is an arsenical ant poison (King, 1950). Lye is the Atropine (all sources) . 8 4 6 Barbiturates . . 1 2 7 commonest in North Carolina (Arena, 1948) and

Disinfectants . . 9 4 to kerosene on September 29, 2021 by guest. Iron . . 1 6 18 Hungary (Csoke, 1948). Poisonings due Methyl salicylate . . 4 8 18 outnumber all others in Manila (Tupas and Dauis- Morphine .4 6 7 Quinine .3 1 1 3 Lawas, 1950) and Queensland (Ryan, 1951). Of Strychnine .9 12 10 cases there was one Vegtable poisons, including 1,086 in Queensland, only those containing atropine 6 4 15 instance of ferrous sulphate poisoning, but this was the commonest poison recorded in Manchester by too much importance to these small figures is Holzel and James. It accounted for six of their illustrated by the entry for methyl salicylate; a 34 cases, most of which were due to medicinal sub- progressive increase in wintergreen poisoning is not probable, since 14 of these deaths occurred in Since this paper was accepted we have received the following rise due to figures of deaths in England and Wales, under 10 years of age, in 1944-45. There was a similar transient 1950-51: iron tablets 15, antihistamines 14. strychn 10, aspirin 6, quinine, with eight deaths in 1940-41. On the other methyl salicylate 5, amidone 2. Arch Dis Child: first published as 10.1136/adc.28.140.259 on 1 August 1953. Downloaded from ACCIDENTAL POISONING IN CHILDHOOD 265 stances. Bearing in mind such regional variations, disturbance in early childhood were increasing, this we believe that our figures are broadly applicable to might influence the poisoning rate. A child who Great Britain. feels insecure may revert to infantile behaviour, with Discusson a renewed tendency to transfer objects to his mouth. The Rising Trend. Evidence has been presented This is a very theoretical consideration, but should to show that accidental poisoning has been increas- perhaps not be dismissed completely. ing in the child population, certainly since 1948 and The one clear fact that emerges is that the rise in probably since 1935. Some additional lines of medicinal poisoning has occurred during a period investigation which did not invalidate this conclusion of increased prescribing. It may reasonably be can now be briefly mentioned. expected that, if the amount of prescribing becomes Variations in the toddler population of Edinburgh stabilized, the rapid increase in poisoning will cease. and Aberdeen in recent years were found to have Prevention. Poisoning is one of the minor acci- been negligible by comparison with the increase of dents of childhood. For every child who dies from poisoning. this cause, 20 are killed on the roads. Poisoning is There has not been any considerable shift of cases on the increase, however, at a time when we are from neighbouring hospitals; the records we have accustomed to diminishing diseases, and most of consulted show that the other hospitals have had a that increase is due to medicinal poisons. The similar increase. problem is thus one for the medical profession in We have found no evidence that improvement in particular. diagnosis has played a significant part in raising the For the purpose of prevention, more information hospital incidence, although some cases of iron is needed. For example, it may be found that the poisoning may have been overlooked in earlier years. rise which we have described, and which has been It is obvious that the rise in medicinal noted in abrupt Manchester, is characteristic only of large Protected by copyright. poisoning occurred at about the same time as the towns; the increase recorded by Ryan in Brisbane introduction of the National Health Service, but it did not occur in the rural areas of Queensland. It cannot be assumed that this was entirely a matter of is also possible that figures taken from children's cause and effect. For example, Ryan (1951) showed hospitals do not exactly reproduce the national that poisoning increased sharply in Brisbane poisoning pattern (see Appendix C). Children's Hospital from 1946 to 1949, although it Too little is known about the circumstances in is not clear how far this was due to medicines. which poisoning occurs. In any enquiry, the follow- Again, while prescribing has increased by 50% in ing details should be included in the case history: Scotland since 1948, medicinal poisoning has been (1) In what receptacle was the poison kept? For trebled. This difference is so great that a possible example, was it in a box or a screw-cap bottle, or cause for it has been sought. If it were due to grow- was it in a receptacle intended for something else, ing parental carelessness or a greater readiness to such as kerosene in a lemonade bottle? (2) Was it bring children for treatment, a comparable rise under lock and key? (3) By whom was the poison would be expected in poisoning due to household given if it was not self-administered? (4) What are http://adc.bmj.com/ substances but the increase in household poisoning the social conditions, e.g., the number of persons remains linear. It may be that many of the 'new' per room? (5) What is the temperament of the child, prescriptions have gone to homes where overcrowd- and does the parent-child relationship seem to be ing and lack of experience in dealing with medicines good? might cause them to be poorly guarded. There has Preventive efforts in the meantime should be been a growing tendency to prescribe tablets rather chiefly devoted to the medicinal cases, and the family

than liquids. In Aberdeen in 1931 liquid medicines doctor has an important part to play. He should on September 29, 2021 by guest. were dispensed twice as commonly as tablets, but ensure that the dangers of medicines are explained since 1946 the two forms of prescription have been to their recipients, that medicines are dispensed in a roughly equal in frequency (Fraser, 1953). Even form in which the danger is minimized, and that when liquids were more in favour, tablets were the particular care is given to what medicines are pre- more frequent cause of poisoning (Appendix A). scribed in homes where there are young children. A relative increase in the dispensing of tablets would Parents must be encouraged to keep all medicines therefore raise the poisoning rate, but since this out of the reach of small children; even aspirin and factor seems to have been fully developed before laxative tablets are potentially lethal. A specific 1948, it cannot have played any part in the later rise. warning should be given when prescribing ferrous The personality of the child who takes poison by sulphate, strychnine preparations, and oil of winter- accident remains to be considered. If emotional green. 266 ARCHIVES OF DISEASE IN CHILDHOOD Arch Dis Child: first published as 10.1136/adc.28.140.259 on 1 August 1953. Downloaded from Sua_ry We are greatly indebted to Professor R. W. B. Ellis and Professor John Craig for their advice and encourage- Among children attending two Scottish hospitals, ment: to the Medical Superintendent of the Edinburgh accidental poisoning has become much more Northern Group of Hospitals and to Dr. 1. 0. Forfar for giving us access to the records of the Western General frequent during the past 20 years. An attempt has Hospital and Leith Hospital: to Dr. D. N. Nicholson for been made to determine whether this represents a allowing us to include cases under his care: to the true increase of poisoning in the child population. Registrars-General for Scotland and England and Wales For the years 1935-48 the evidence favours this but for supplying us with information not included in their reports: to Miss C. Brydone for her help in the preparation is not conclusive. There can be no doubt, however, of the figures: and especially to Dr. Lilli Stein for detailed of a sharp general increase in the years 1949-51; it is statistical guidance. chiefly explained by a rise in the accidental ingestion of medicines. REFERENCES Arena. J. M. (1948). J. Pediat.. 32. 208. The poisons most commonly swallowed by Csoke. L. (1948). Nepegeszegkgy, 29. 609. Abstract (1951) in Amer. Scottish children are disinfectants (not lye), barbi- J. Dis. Child.. 82 211. Forbes. G. (1947). Brir. med. J.. 1. 367. turates, kerosene and camphor liniments. Those Fraser, M. S. (1953). Pharm. J.. in the press. Hokzel A. and James, T. (1951). Med. Offr.. 86. 169. which are most often fatal to children in Great King, A. L. (1950). Permanente Fdn med. Bull.. 8. 2'. Britain are ferrous sulphate. strychnine, methyl Rvan, D. C. (1951). Mfed. J. Aust..-2. 702. SWinscow. D. (1953). Archives of Disease in Chiidhood. 28. 26. salicylate and the disinfectants. Tupas. A. V. and Dauis-Lawas. D. (1950). Acra med. philipp.. 7. 61

APPENDIX A

Edinburgh Aberdeen Mortality Mort. EW. E. and Ab. Ab. Year H. M. A. V. H. M. A. V. EW. S. H. M. T. L. BS. Protected by copyright. 1931 1 1 1 2 - 1 2 - 17 2 9 4 - 2 100 1932 - 2 1 1 3 - - - 19 1 9 5 2 - 122 1933 3 - - - 2 - 2 - 12 6 5 1 - - 125 1934 4 - - - 4 - - - 15 4 6 6 - - 131 1935 1 1 - - - 12 - 5 7 - - 139 1936 - 2 - - 3 - 2 - 16 1 7 8 1 1 173 1937 5 3 2 - 5 2 1 1- 1 - 8 4 4 - 151 1938 3 1 1 1 3 - I - 1 6 5 6 6 - - 149 1939 4 1 2 - 8 - - - 15 2 6 6 1 - 150 1940 3 4 4 - 3 - I - 22 3 7 10 3 1 135 1941 4 - 4 - 3 1 2 1 27 5 7 12 - I 160 1942 2 6 2 1 4 2 3 - 23 7 11 7 7 1 178 1943 9 2 2 1 4 4 1 1 18 3 7 6 5 - 185 1944 8 3 2 - 5 1 3 1 18 3 6 3 3 1 180 1945 9 4 2 1 5 5 1 - 30 2 6 8 7 2 220 1946 6 6 5 - 5 6 1 - 23 2 6 12 8 3 230 1947 5 5 5 3 11 5 2 1 36 4 1 3 1 7 7 2 245 1948 6 9 2 4 7 5 2 - 31 5 15 13 14 - 255 1949 15 7 1 2 10 14 4 2 35 5 10 18 19 2 255 266 1950 4 21 3 4 8 18 3 2. 39 5 ? ' 33 6 http://adc.bmj.com/ 1951 10 20 2 3 8 23 3 3 ? 6 ? ? 36 6 278

EW. =England and Wales S. = Scotland. E. =Edinburgh. Ab. =Aberdeen. H. = Household poisons. M. = oral medicines. A.=medical applcations. V.=vegetable poisons. T. =tablets, etc. L =liquids. BS.=burns and scalds. Four cases of unknown poisons are cxcluded. In six instances of 'medicinal' poisoning, it is either not ckar whether the poison was taken in liquid or solid form, or else the child was known to have taken both.

APPENDIX B on September 29, 2021 by guest. STATLSTICAL ANALYSIS of cases or deaths. These moving averages compensate average to some extent for annual fluctuations. The purpose of tbe analyses is to describe the of rates of over the 21-year period for each set of figures, In those groups in which comparisons time-trend increase are made, lines or curves have been fitted by to compare these trends and to seek any significantly be rates of increase. the method of least squares, and these lines will different or similar discussed in detail. Method Results In those groups (Figs. 4, 5 and 6), in which only a Posoumgs fro All Causes, Ed g and Aberdee general description is indicated and no further analyses 1931-1951. From the original figures, the mean=22-0 or comparisons are made, the average time-trend is and the standard deviation of mean= 17 2. shown by three-year moving averages of actual numbers The curve which has been fitted indicates the trend Arch Dis Child: first published as 10.1136/adc.28.140.259 on 1 August 1953. Downloaded from ACCIDENTAL POISONING IN CHILDHOOD 267 much more closely than a straight line, and in spite of averaged 0- 8 added poisoning cases each year. The the divergencies from the curve the correlation coefficient divergencies of the 'expected' numbers are relatively is 0-912. The S.D. from the average time-trend is 4-1, unimportant, as can be seen from the correlation co- much lower than the S.D. of 17-2 from the 21-year mean. efficient of 0-826. The S.D. from the average trend is The equation of the curve estimating the 'expected' 3-4, as compared with the S.D. of 5-9 from the 21-year number of poisoning cases is P-=3 909x(I 137)Y mean. where Y=the year-number after 1930. The increments Medicinal Poisnings. The mean=12-4, the S.D. of throughout have been on the average 13- 70,, of the the man= 12-8. previous year's total, meaning that in the early years there No curve was found to describe the fitted trend as was less than one additional case per annum, but in the well as the pair of straight lines, which have a correlation more recent years the increments averaged six to eight coefficient of 0 847. The medicinal poisonings followed additional cases per annum. It is clear from the diagram a steady upward trend during the period 193147 (Me= that in fact the rate of increase in the last three or four 0-9044Y--0-9044), similar to the household poisons. years has been even steeper than that given in our The two coefficients of Y are very similar. The trend of equation, and the divergencies between the 'expectations' medicinal poisonings then changed abruptly, and between and the actual observations are most consistent in the 1948 and 1951 is represented by the equation Me= 10-9Y years 1949-1951. -178-3. The S.D. from the average time-trend is 2-9, Buns and Scalds, Aberdeen, 1931-1951. The mean= a remarkably low figure compared with the S.D. of 181-8, the S.D. of the mean=53-3. 12-8 from the 21-year mean. The equation of the fitted trend, giving an estimate of In Fig. 8 the average time-trend for the period 193547 the average number of burns in terms of the year of is also shown. This line allows for the possibility that the occurrence is Be=89-5+8 4Y. The increase in the period 1931-35 was a period of fall, but differs very little number of cases has been steady. The average number from the 193147 line. of additional cases per annum throughout the two Up to 1948, the average increment was nearly one decades has been between eight and nine. The 'expected' additional case per annum, but since 1948 it has been numbers correspond particularly well with the actual nearly 11 added cases per annum. The difference between Protected by copyright. numbers treated in recent years. The divergencies from these two rates of increase is highly significant. the average time-trend, e.g. the low figures in the early war years, are not in fact of great importance, as is evident from the correlation coefficient of 0-953. The Conclusions S.D. from the average time-trend (16-6) is small compared The similarity between the burns and the household with the S.D. from the 21-year mean (53-3). poisonings lies in the fact that both have an average Housebold Poisonei. The mean=9 7, the S.D. of the trend which is linear. On the other hand, there has been mean=5-9. a distinct change in the trend of the medicinal poisoning The equation of the line is He=0 8804±0-799Y. The cases. It is not suggested here that there is a causal numbers fall into a fairly regular pattern, and the time- connexion between that change in the trend and the trend is one of steady increase between 1931 and 1951. period in which it seems to have occurred. The 'expected' numbers often differ from the actual numbers, but they agree extremely closely with the 3-year LILLI STEIN, moving averages. The increase in household poisonings Department ofSocial Medicine, University ofEdinburgh. http://adc.bmj.com/

APPENDIX C A NOTE ON LEITH HOSPITAL The figures are small and take no account of out- Leith is the port of Edinburgh. The general hospital patients, but they do show the general rising trend and there draws its patients largely from crowded tenements, the recent medicinal preponderance, although the latter and differs in that respect from the children's hospitals of was not clearly seen until 1950. Edinburgh and Aberdeen where the patients represent The common poisons at Leith were camphor (10 cases), on September 29, 2021 by guest. almnost all social grades. It has about 25 beds for children, ammonia (six), bleach (five), disinfectants (four) and and 73 cases of poisoning were admitted between 1931 petrol (four). The commonest medicinal poisons were and 1951. This small series has been tabulated in three- aspirin, the opium group and digitalis (three cases of year groups: each). Strychnine poisoning occurred once and was due to Easton's tablets; it caused the only death among the Source of Poison 1931- 1934- 1937- 1940- 1943- 1946- 1949- 73 cases. 33 36 39 42 45 48 51 The pattern of individual poisons is rather different Household 2 2 3 6 4 8 7 from that found in the two hospitals for children. It Medicinal 1 3 3 3 5 9 14 suggests that the social groups which a hospital serves may help to determine the variety of poisonings seen Vegetable I 0 0 0 0 1 1 there. The difference is not gross, but it should receive Total 4 5 6 9 9 18 22 attention in any future enquiry.